Evaluation of acute fixation strength for mechanical tacking devices and fibrin sealant versus polypropylene suture for laparoscopic ventral hernia repair

BACKGROUND

The purpose of this comparative study is to evaluate the acute fixation strength of mechanical tacking devices and fibrin sealant against polypropylene suture for laparoscopic ventral hernia repair.

METHODS

Three metallic mechanical tacking devices (ProTack, Salute, EndoANCHOR), 4 absorbable tacking devices (AbsorbaTack, PermaSorb, I-Clip, and SorbaFix), and 2 types of fibrin sealant (Tisseel, Artiss) were compared with 0-polypropylene suture. Three constructs from each device or an amount of sealant sufficient to cover a 3 × 3 cm(2) area were used to affix a 4 × 3 cm piece of absorbable barrier-coated mesh (Proceed, Ethicon, Inc) to the peritoneal surface of porcine abdominal wall. Ten samples were completed for each fixation modality. Acute fixation strength was measured via a lap shear test on an Instron tensiometer.

RESULTS

Acute fixation strength was significantly greater for suture (59.7 7.2 N) compared with all laparoscopic tacking devices and to fibrin sealant (P < .001 for all comparisons). Protack (29.5 ± 2.8 N) was stronger than Absorbatack (13.2 ± 3.7 N; P = .029). Protack, Permasorb, SorbaFix, and I-clip were stronger than fibrin sealant (P < .05 for all comparisons).

CONCLUSIONS

The acute fixation strengths of metallic or absorbable tacks as well as fibrin sealant are all significantly less than that achieved with polypropylene suture. These factors should be considered in selecting the type of mechanical fixation for patients undergoing laparoscopic ventral hernia repair.

Evaluation of fenestrated and non-fenestrated biologic grafts in a porcine model of mature ventral incisional hernia repair

INTRODUCTION

The purpose of this study is to compare the tissue incorporation of a novel fenestrated and non-fenestrated crosslinked porcine dermal matrix (CPDM) (CollaMend™, Davol Inc., Warwick, RI) in a porcine model of ventral hernia repair.

METHODS

Bilateral abdominal wall defects were created in 12 Yucatan minipigs and repaired with a preperitoneal or intraperitoneal technique 21 days after hernia creation. Animals were randomized to fenestrated or non-fenestrated CPDM for n = 6 pieces of each graft in the preperitoneal or intraperitoneal location. All animals were sacrificed at 1 month. Adhesion characteristics and graft contraction/growth were measured by the Garrard adhesion grading scale and transparent grid overlay. Histological analysis of hematoxylin and eosin (H&E)-stained slides was performed to assess graft incorporation. Tissue incorporation strength was measured by a T-peel tensile test. The strength of explanted CPDM alone and de novo CPDM was measured by a uniaxial tensile test using a tensiometer (Instron, Norwood, MA) at a displacement rate of 0.42 mm/s. Statistical significance (P < 0.05) was determined for histological analysis using a Kruskal-Wallis non-parametric test with a Bonferroni correction, and for all other analyses using a two-way analysis of variance (ANOVA) with a Bonferroni post-test or a Kruskal-Wallis non-parametric test with a Dunn's post-test.

RESULTS

Intraperitoneal placement of fenestrated CPDM resulted in a significantly higher area of adhesions and adhesion score compared to the preperitoneal placement of fenestrated CPDM (P < 0.05). For both preperitoneal and intraperitoneal placement, histological findings demonstrated greater incorporation of the graft due to the fenestrations. No significant differences were detected in the uniaxial tensile strengths of the graft materials alone, either due to the graft type (non-fenestrated vs. fenestrated) or due to the placement location (preperitoneal vs. intraperitoneal). The incorporation strength (T-peel force) was significantly greater for fenestrated compared to non-fenestrated CPDM when placed in the preperitoneal location (P < 0.01). The incorporation strength was also significantly greater for fenestrated CPDM placed in the preperitoneal location compared to fenestrated CPDM placed in the intraperitoneal location (P < 0.05).

CONCLUSIONS

Fenestrations in CPDM result in greater tissue incorporation strength and lower adhesion area and score when placed in the preperitoneal location. Fenestrations in CPDM allow for greater tissue incorporation without accelerating graft degradation. Fenestrations may be placed in CPDM while still allowing adequate graft strength for intraperitoneal and preperitoneal hernia repairs at 1 month in a porcine model.

Prospective evaluation of adhesion characteristics to intraperitoneal mesh and adhesiolysis-related complications during laparoscopic re-exploration after prior ventral hernia repair

BACKGROUND

The purpose of this study was to characterize the adhesion characteristics of absorbable- and nonabsorbable-barrier-coated meshes and to report adhesiolysis-related complications during laparoscopic re-exploration after prior ventral hernia repair.

METHODS

Under an IRB-approved protocol, patients undergoing laparoscopic re-exploration after prior intraperitoneal mesh placement were prospectively graded intraoperatively for adhesion tenacity (0-4), adhesion surface area (0 = 0%, 10 = 100%), and ratio of adhesiolysis time to mesh surface area (min/cm(2)). Adhesiolysis-related complications were also recorded. Data are given as mean ± SD. Statistical significance (P < 0.05) was determined using the t test and Fisher's exact test.

RESULTS

From March 2006 to March 2009, 69 patients underwent laparoscopic surgery after prior intraperitoneal mesh placement for ventral hernia repair. Previous meshes were absorbable-barrier-coated mesh (n = 18), permanent-barrier composite mesh [Composix® (n = 17)], permanent-barrier noncomposite mesh [DualMesh® (n = 14)], uncoated polypropylene mesh (n = 12), and biologic mesh (n = 8). Indications for laparoscopic re-exploration were recurrent ventral hernia (n = 58), chronic pain (n = 3), cholecystectomy (n = 3), parastomal hernia (n = 2), small bowel obstruction (n = 1), nephrectomy (n = 1), and Nissen fundoplication (n = 1). Adhesions to DualMesh were less tenacious (P < 0.05) compared to all other meshes. Surface area of adhesions to DualMesh were less (P < 0.05) than to Composix and to uncoated polypropylene mesh, but not to absorbable-barrier-coated and biologic meshes. Adhesiolysis time:mesh surface area was less (P < 0.05) for DualMesh compared to Composix, uncoated polypropylene, and biologic mesh, but not to absorbable-barrier-coated mesh. Adhesiolysis-related complications occurred in two (16.7%) (P = ns) patients with uncoated polypropylene mesh, one cystotomy and one enterotomy; both were repaired laparoscopically. There were two (16.7%) (P = ns) conversions to an open procedure: one converted patient had Composix (6.7%) and one had absorbable-barrier-coated mesh (5.9%). There were no adhesiolysis-related complications with these meshes. There were no adhesiolysis-related complications or conversions to open in the DualMesh or biologic mesh groups.

CONCLUSIONS

Adhesion characteristics of mesh placed intraperitoneally and adhesiolysis-related complications during laparoscopic re-exploration after ventral hernia repair are associated with unique properties of the mesh and/or barrier.

Single-incision laparoscopic cholecystectomy: initial experience with critical view of safety dissection and routine intraoperative cholangiography

BACKGROUND

Single-incision laparoscopic cholecystectomy (SILC) is emerging as a potentially less invasive alternative to standard laparoscopic cholecystectomy and natural orifice transluminal endoscopic surgery cholecystectomy. As this technique is more widely used, it is important to maintain well-established practices of the critical view of safety (CVS) dissection and intraoperative cholangiography (IOC). We present our initial experience with SILC using CVS dissection and routine IOC.

STUDY DESIGN

Fifty-four patients with biliary colic were offered SILC, which was performed through the umbilicus. CVS with photo documentation was attained before clipping and transecting the cystic structures. IOC was done using various needle puncture techniques. Assessment of CVS was carried out by independent surgeon review of operative still photos or videos using a 3-point grading scale: visualization of only 2 ductal structures entering the gallbladder; a clear triangle of Calot; and separation of the base of the gallbladder from the cystic plate.

RESULTS

SILC was performed in 54 patients (15 male and 39 female). Six patients required 1 supplementary 3- or 5-mm port. Complete IOC was successful in 50 of 54 patients (92.6%). CVS was achieved at the time of operation in all 54 patients. Photo documentation review confirmed 3 of 3 CVS criteria in 32 (64%) patients, 2 of 3 in 12 patients (24%), 1 of 3 in 3 patients (6%), and 0 in 3 patients (6%).

CONCLUSIONS

As laparoscopic cholecystectomy becomes less invasive, proven safe dissection techniques should be maintained. Dissection to obtain the CVS should be the goal of every patient and IOC can be accomplished in a high percentage of patients. This approach places patient safety considerations foremost in the evolution of minimally invasive cholecystectomy.

Informed consent: cultural and religious issues associated with the use of allogeneic and xenogeneic mesh products

BACKGROUND

Our aim was to investigate the views of major religions and cultural groups regarding the use of allogeneic and xenogeneic mesh for soft tissue repair.

STUDY DESIGN

We contacted representatives from Judaism, Islam, Buddhism, Hinduism, Scientology, and Christianity (Baptists, Methodists, Seventh-Day Adventists, Catholics, Lutherans, Church of Jesus Christ of Latter-Day Saints, Evangelical, and Jehovah's Witnesses). We also contacted American Vegan and People for the Ethical Treatment of Animals (PETA). Standardized questionnaires were distributed to the religious and cultural authorities. Questions solicited views on the consumption of beef and pork products and the acceptability of human-, bovine-, or porcine-derived acellular grafts.

RESULTS

Dietary restrictions among Jews and Muslims do not translate to tissue implantation restriction. Approximately 50% of Seventh-day Adventists and 40% of Buddhists practice vegetarianism, which may translate into a refusal of the use of xenogeneic tissue. Some Hindus categorically prohibit the use of human tissue and animal products; others allow the donation and receipt of human organs and tissues. PETA is opposed to all uses of animals, but not to human acellular grafts or organ transplantation. Some vegans prefer allogeneic to xenogeneic tissue. Allogeneic and xenogeneic acellular grafts are acceptable among Scientologists, Baptists, Lutherans, Evangelicals, and Catholics. Methodists, Jehovah's Witnesses, and The Church of Jesus Christ of Latter-Day Saints leave the decision up to the individual.

CONCLUSIONS

Knowledge of religious and cultural preferences regarding biologic mesh assists the surgeon in obtaining a culturally sensitive informed consent for procedures involving acellular allogeneic or xenogeneic grafts.

Clinical predictors of operative complexity in laparoscopic ventral hernia repair: a prospective study

BACKGROUND

Because of uncertainties about the complexity of laparoscopic ventral hernia repair for varying patient populations, surgeons may be reluctant to perform this procedure. This study aimed to delineate the risk factors that can be identified in the preoperative setting predictive of longer operative times and complexity in laparoscopic ventral hernia repair.

METHODS

Patient demographics including body mass index (BMI), comorbidities, previous laparoscopic and open surgical procedures, ventral hernia repairs, and hernia characteristics (defect size and location, adhesions, incarceration) were recorded prospectively. Data are given as mean +/- standard deviation. Times (min) required for abdominal access, adhesiolysis, and mesh placement as well as the total operative time were recorded during each case as outcome measures of operative difficulty. Univariate analyses were performed with the t-test or the Mann-Whitney U test as well as multivariate analyses using the stepwise analysis of covariance model to determine demographic and clinical variables influencing operative times.

RESULT

The study enrolled 180 patients (78 men and 102 women) with a mean age of 54.8 +/- 12.2 years and a mean BMI of 33.3 +/- 13.0 kg/m(2). Multivariate analysis demonstrated significantly longer (p < 0.05) adhesiolysis and total operative times for patients with prior ventral hernia repairs, suprapubic hernia, bowel adhesion to the abdominal wall or hernia sac, and larger hernia defect. The total operative time also was increased (p < 0.05) with incarcerated hernia contents. Mesh placement time was increased (p < 0.05) with incarcerated hernia contents, suprapubic hernia location, hernias requiring larger mesh for repair, and decreased postgraduate year of the surgical assistant. The time required to obtain abdominal access was longer (p < 0.05) with a greater BMI and a higher American Society of Anesthesiology (ASA) classification. The operative times were not increased with a history of peritonitis, diabetes, immunosuppression, cancer, or with higher numbers of previous open or laparoscopic surgeries.

CONCLUSIONS

At least 10 preoperatively identifiable patient variables, either alone or in combination, are predictive of prolonged operative times during laparoscopic ventral hernia repair and may be used as surrogates to determine the complexity of a minimally invasive approach.

Differential regulation of MMP-2 in the gastrohepatic ligament of the gastroesophageal junction

INTRODUCTION

Ligamentous attachments maintain the normal anatomic position of the gastroesophageal (GE) junction. Failure of these elastic ligaments through an alteration in collagen synthesis, deposition, and metabolism may be a primary etiology of hiatal hernia formation. Differential expression of zinc-dependent matrix metalloproteinases (MMPs) is largely responsible for collagen remodeling. The purpose of this study was to survey baseline levels of MMPs in supporting ligaments of the GE junction from patients without hiatal hernia.

METHODS

Following an institutional review board-approved protocol, plasma and tissue biopsies of the gastrohepatic ligament (GHL), gastrophrenic ligament (GPL), and phrenoesophageal ligament (PEL) were obtained in six patients without a hiatal hernia during laparoscopic anterior esophageal myotomy for achalasia. Total protein extracts from tissue biopsies were analyzed for elastases MMP-2, -9, and -12 and collagenases MMP-1, -3, -7, -8, and -13 using a multiplex profiling kit (R&D Systems, Minneapolis, MN). Data are reported as mean +/- standard deviation. Statistical significance (p < 0.05) was determined using Tukey's test and analysis of variance.

RESULTS

In control patients without hiatal hernias, increased levels of MMP-2 (p < 0.02) were detected in the GHL compared with the GPL and PEL, respectively. Tissue levels of MMP-1, -12, and -13 were not detectable.

CONCLUSIONS

Gelatinase-A (MMP-2) is present in the GHL and plasma of control patients. The GHL may provide the primary GE junction supporting ligament to compare tissue from patients with type I (sliding) and type III (paraesophageal) hiatal hernias to examine the role of altered collagen metabolism in hiatal hernia formation.

Use of video capsule endoscopy in the setting of recurrent subacute small-bowel obstruction

HYPOTHESIS

Video capsule endoscopy (VCE) can be used to diagnose subacute intestinal obstruction in patients with otherwise negative imaging studies.

PATIENTS AND METHODS

Nine patients with symptoms consistent with intermittent small-bowel obstruction who received a VCE and ultimately required surgical intervention.

RESULTS

Patients were identified who had symptoms consistent with subacute bowel obstruction and a negative diagnostic work-up prior to VCE. All 9 patients underwent several radiologic and endoscopic examinations with no clear etiology for their symptoms. Ultimately, in every case, a stricture or mass was found to be the cause of the obstruction at either the time of VCE or exploratory laparotomy/laparoscopy.

CONCLUSIONS

Patients can have a small-bowel stricture or mass that can cause symptoms of subacute small-bowel obstruction. Diagnosis of the lesion may be difficult in these patients and can often result in multiple nondiagnostic radiologic and endoscopic examinations. VCE can be helpful in finding these lesions, leading to surgical resection of the diseased bowel and a cure for the patient's signs and symptoms.

120-Day Comparative Analysis of Adhesion Grade and Quantity, Mesh Contraction, and Tissue Response to a Novel Omega-3 Fatty Acid Bioabsorbable Barrier Macroporous Mesh After Intraperitoneal Placement

Purpose. This study aimed to evaluate adhesion formation, mesh contraction, and tissue response to an omega-3 fatty acid barrier—coated lightweight polypropylene mesh (C-Qur) after intra-abdominal placement, and compare these properties to those of other commercially available meshes. Materials and methods. After randomization, 3 × 3 cm pieces of Atrium C-Qur, Mesh ProLite Ultra, Composix, Parietex, Proceed, Sepramesh, and DualMesh were sewn to the intact peritoneum on either side of a midline incision in 41 New Zealand white rabbits. Necropsy was performed at 120 days, and explants were evaluated for adhesion grade, adhesion amount, and mesh contraction. Histologic evaluation included extent of capsule formation, abdominal wall tissue ingrowth, degrees of inflammation and vascularization of the surrounding tissue, and the presence of mesothelialization. Results. There were no significant differences between the C-Qur mesh and the commercially available meshes tested with regard to adhesion grade or amount, although percentage adhesion coverage for the C-Qur mesh was much less than for Composix and Proceed. The C-Qur mesh contracted less than all meshes, significantly less ( P < .05) than DualMesh or Proceed. DualMesh exhibited the greatest amount of capsule formation and inflammation on its parietal side as compared with the other meshes. Conclusions. Placing lightweight polypropylene mesh with an omega-3 fatty acid barrier coating intraperitoneally results in more favorable adhesion characteristics compared with Composix and Proceed meshes at 120-day explantation after intraperitoneal placement. The minimal amount of contraction and favorable tissue response in comparison to other commercially available meshes makes C-Qur mesh a practical alternative for laparoscopic and open ventral hernia repair.

Primary and overall success rates for clinical outcomes after laparoscopic, endoscopic, and open pancreatic cystgastrostomy for pancreatic pseudocysts

BACKGROUND

Internal drainage of pancreatic pseudocysts can be accomplished by traditional open or minimally invasive laparoscopic or endoscopic approaches. This study aimed to evaluate the primary and overall success rates and clinical outcomes after laparoscopic, endoscopic, and open pancreatic cystgastrostomy for pancreatic pseudocysts.

METHODS

Records of 83 patients undergoing laparoscopic (n = 16), endoscopic (n = 45), and open (n = 22) pancreatic cystgastrostomy were analyzed on an intention-to-treat basis.

RESULTS

There were no significant differences (p < 0.05) in the mean patient age (years), gender, body mass index (BMI) (kg/m(2)), etiology of pancreatitis (% gallstone), or size (cm) of pancreatic pseudocyst between the groups. Grade 2 or greater complications occurred within 30 days of the primary procedure for 31.5% of the laparoscopic patients, 15.6% of the endoscopic patients, and 22.7% of the open patients (nonsignificant differences). The follow-up evaluation for 75 patients (90.4%) was performed at a mean interval of 9.5 months (range, 1-40 months). The primary compared with the overall success rate, defined as cyst resolution, was 51.1% vs. 84.6% for the endoscopic group, 87.5% vs. 93.8% for the laparoscopic group, and 81.2% vs. 90.9% for the open group. The primary success rate was significantly higher (p < 0.01) for laparoscopic and open groups than for the endoscopic group, but the overall success rate was equivalent across the groups (nonsignificant differences). Primary endoscopic failures were salvaged by open pancreatic cystgastrostomy (n = 13), percutaneous drainage (n = 3), and repeat endoscopic drainage (n = 6).

CONCLUSIONS

Laparoscopic and open pancreatic cystgastrostomy both have a higher primary success rate than endoscopic internal drainage, although repeat endoscopic cystgastrostomy provides overall success for selected patients.

Incidence of residual choledocholithiasis detected by intraoperative cholangiography at the time of laparoscopic cholecystectomy in patients having undergone preoperative ERCP

INTRODUCTION

The purpose of this study is to determine the incidence of residual common bile duct (CBD) stones after preoperative ERCP for choledocholithiasis and to evaluate the utility of routine intraoperative cholangiography (IOC) during laparoscopic cholecystectomy (LC) in this patient population.

METHODS

All patients who underwent preoperative ERCP and interval LC with IOC from 5/96 to 12/05 were reviewed under an Institutional Review Board (IRB)-approved protocol. Data collected included all radiologic imaging, laboratory values, clinical and pathologic diagnoses, and results of preoperative ERCP and LC with IOC. Standard statistical analyses were used with significance set at p < 0.05.

RESULTS

A total of 227 patients (male:female 72:155, mean age 51.9 years) underwent preoperative ERCP for suspicion of choledocholithiasis. One hundred and eighteen patients were found to have CBD stones on preoperative ERCP, and of these, 22 had choledocholithiasis diagnosed on IOC during LC. However, two patients had residual stones on completion cholangiogram after ERCP and were considered to have retained stones. Therefore, 20 patients overall were diagnosed with either interval passage of stones into the CBD or a false-negative preoperative ERCP. In the 109 patients without CBD stones on preoperative ERCP, nine patients had CBD stones on IOC during LC, an 8.3% incidence of interval passage of stones or false-negative preoperative ERCP. In both groups, there was no correlation (p > 0.05) between an increased incidence of CBD stones on IOC and a longer time interval between ERCP and LC, performance of sphincterotomy, incidence of cystic duct stones, or pathologic diagnosis of cholelithiasis.

CONCLUSIONS

The overall incidence of retained or newly passed CBD stones on IOC during LC after a preoperative ERCP is 12.9%. Although the natural history of residual CBD stones after preoperative ERCP is not known, the routine use of IOC should be considered in patients with CBD stones on preoperative ERCP undergoing an interval LC.

Laparoscopic Management of Adhesive Small Bowel Obstruction

Adhesions from prior surgery are the most common cause of small bowel obstruction (SBO) in the Western world. Although laparoscopic adhesiolysis can be performed safely and effectively, the indications and contraindications to the use of laparoscopic techniques in SBO are not clearly defined. The goal of our study was to determine the outcomes of the laparoscopic approach to SBO and discuss patient considerations for its utilization. We retrospectively surveyed all patients undergoing laparoscopic or attempted laparoscopic adhesiolysis performed by the authors between July 1997 and March 2006. Data obtained included patient demographics, clinical and radiologic presentation, and intraoperative and postoperative course. Thirty-three patients underwent laparoscopic adhesiolysis secondary to a SBO. Mean age was 53.6 years (range, 29–84 years) and 64 per cent (21 of 33) were female. Mean body mass index was 30.0 kg/m2 (range, 22.6–46.1 kg/m2). Thirty-one patients (93.9%) had undergone between one and four abdominal surgeries and seven (21.2%) had a previous episode of SBO. There were no patients with peritonitis. Abdominal CT scan was performed preoperatively in 27 patients (81.8%). Laparoscopy diagnosed the site of obstruction in all patients. Twenty-nine patients (88%) were successfully treated laparoscopically. Conversion to laparotomy was required in four cases as a result of dense adhesions and/or a lack of working space. Mean procedural time was 101 minutes (range, 19–198 minutes). There was one intraoperative complication (enterotomy), which was repaired laparoscopically and did not require conversion. Conversion was associated with significantly increased procedural time (129 versus 93 minutes; P = 0.02), but not blood loss or complications. Average times to passage of flatus and first bowel movement were 2.3 days (range, 0.5–5 days) and 3.2 days (range, 1–6 days), respectively. Seven patients (21.2%) had postoperative complications, including wound infection, urinary tract infection, and acute renal insufficiency, all of which occurred in patients completed laparoscopically. One patient had a recurrent SBO 8 months postoperatively managed by repeat laparoscopic lysis of adhesions. Mean postoperative stay was 6 days (range, 1–19 days). There was no hospital mortality. Laparoscopy is safe and feasible in the management of acute SBO in selected patients. It is an excellent diagnostic tool and is therapeutic in most cases.

Laparoscopic management of adhesive small bowel obstruction

Adhesions from prior surgery are the most common cause of small bowel obstruction (SBO) in the Western world. Although laparoscopic adhesiolysis can be performed safely and effectively, the indications and contraindications to the use of laparoscopic techniques in SBO are not clearly defined. The goal of our study was to determine the outcomes of the laparoscopic approach to SBO and discuss patient considerations for its utilization. We retrospectively surveyed all patients undergoing laparoscopic or attempted laparoscopic adhesiolysis performed by the authors between July 1997 and March 2006. Data obtained included patient demographics, clinical and radiologic presentation, and intraoperative and postoperative course. Thirty-three patients underwent laparoscopic adhesiolysis secondary to a SBO. Mean age was 53.6 years (range, 29-84 years) and 64 per cent (21 of 33) were female. Mean body mass index was 30.0 kg/m2 (range, 22.6-46.1 kg/m2). Thirty-one patients (93.9%) had undergone between one and four abdominal surgeries and seven (21.2%) had a previous episode of SBO. There were no patients with peritonitis. Abdominal CT scan was performed preoperatively in 27 patients (81.8%). Laparoscopy diagnosed the site of obstruction in all patients. Twenty-nine patients (88%) were successfully treated laparoscopically. Conversion to laparotomy was required in four cases as a result of dense adhesions and/or a lack of working space. Mean procedural time was 101 minutes (range, 19-198 minutes). There was one intraoperative complication (enterotomy), which was repaired laparoscopically and did not require conversion. Conversion was associated with significantly increased procedural time (129 versus 93 minutes; P = 0.02), but not blood loss or complications. Average times to passage of flatus and first bowel movement were 2.3 days (range, 0.5-5 days) and 3.2 days (range, 1-6 days), respectively. Seven patients (21.2%) had postoperative complications, including wound infection, urinary tract infection, and acute renal insufficiency, all of which occurred in patients completed laparoscopically. One patient had a recurrent SBO 8 months postoperatively managed by repeat laparoscopic lysis of adhesions. Mean postoperative stay was 6 days (range, 1-19 days). There was no hospital mortality. Laparoscopy is safe and feasible in the management of acute SBO in selected patients. It is an excellent diagnostic tool and is therapeutic in most cases.

Evaluation of acellular human dermis reinforcement of the crural closure in patients with difficult hiatal hernias

BACKGROUND

Biologic prosthetics may circumvent mesh-related complications at the esophageal hiatus by becoming remodeled by native cells. We present our experience with acellular human dermal matrix in the repair of difficult hiatal hernias (HH).

METHODS

Records of 17 patients who underwent laparoscopic HH repair using acellular human dermis to buttress the crural closure were analyzed. Hernias were paraesophageal (PEH) in 12 patients, large type 1 in 1 patient, and recurrent after prior HH repair in 4 patients. Barium swallow (BAS) was obtained 6-12 months after surgery. (Data are presented as mean +/- standard deviation.)

RESULTS

Mean patient age was 65 +/- 12 years and BMI was 31 +/- 4. Mean gastroesophageal (GE) junction distance above the diaphragm in the PEHs was 4.9 +/- 1.5 cm; 9 of 12 patients with PEH had more than 50% of the stomach in the chest. Mean operating time was 273 +/- 48 min. Average hiatal defect size was 4.7 x 2.7 cm, with 4.2 +/- 1.2 sutures used to close the crura. Nissen fundoplication was performed in all patients, esophageal lengthening in four patients, and anterior gastropexy in three patients. Mean hospital length of stay (LOS) was 2.3 +/- 0.8 days. Mean followup was 14.4 +/- 4.4 months. Postoperatively, only one (6%) patient had heartburn/regurgitation, one (6%) had mild dysphagia, and two (12%) take proton pump inhibitors. Followup BAS at 10.3 +/- 4.9 months after surgery showed small recurrent hernias in two patients (12%), but only one was symptomatic. In addition, there was one symptomatic failure of a redo Nissen in an obese patient. Reoperative gastric bypass 15 months later showed an intact crural closure with a remodeled buttress site.

CONCLUSIONS

Acellular human dermal matrix may be an effective method to buttress the crural closure in patients with large hiatal hernias. Longer followup in larger numbers of patients is needed to assess the validity of this approach.

Absorbable mesh reinforcement of a stapled pancreatic transection line reduces the leak rate with distal pancreatectomy

Pancreatic leak remains a significant cause of morbidity after distal pancreatectomy. We report the use of an absorbable mesh to reinforce a stapled pancreatic transection line for distal pancreatectomy. Forty consecutive distal pancreatectomies (33 open and 7 laparoscopic) were performed since the introduction of mesh reinforcement. We utilized an inclusive definition of pancreatic leak to critically evaluate the staple line reinforcement material. In addition, we compared the pancreatic leak rate for this case series with the antecedent 40 cases where mesh reinforcement was not available. In the prospective series there was 1 leak in 29 cases (3.5%) in which mesh reinforcement was utilized, and 4 leaks in 11 cases (36%) when mesh was not utilized (p < 0.005). The 12.5% leak rate for the 40 cases during the prospective period, compared favorably to the 27.5% leak rate for the 40 cases preceding the study period (p = 0.09). Twenty-nine cases receiving mesh compared favorably to the 23 stapled cases in the control series, reducing leak rate from 22 to 3.5% (p = 0.04). Mesh reinforcement of the stapled pancreatic transection line reduced the pancreatic leak rate after distal pancreatectomy. Mesh reinforcement was possible with open or laparoscopic resections. No complications were attributable to the use of absorbable mesh.

Outcomes analysis of laparoscopic resection of pancreatic neoplasms

BACKGROUND

Experience with laparoscopic resection of pancreatic neoplasms remains limited. The purpose of this study is to critically analyze the indications for and outcomes after laparoscopic resection of pancreatic neoplasms.

METHODS

The medical records of all patients undergoing laparoscopic resection of pancreatic neoplasms from July 2000 to February 2006 were reviewed. Data are expressed as mean +/- standard deviation.

RESULTS

Laparoscopic pancreatic resection was performed in 22 patients (M:F, 8:14) with a mean age of 56.3 +/- 15.1 years and mean body mass index (BMI) of 26.3 +/- 4.5 kg/m2. Nine patients had undergone previous intra-abdominal surgery. Indications for pancreatic resection were cyst (1), glucagonoma (1), gastrinoma (2), insulinoma (3), metastatic tumor (2), IPMT (4), nonfunctioning neuroendocrine tumor (3), and mucinous/serous cystadenoma (6). Mean tumor size was 2.4 +/- 1.6 cm. Laparoscopic distal pancreatectomy was attempted in 18 patients and completed in 17, and enucleation was performed in 4 patients. Laparoscopic ultrasound (n = 10) and a hand-assisted technique (n = 4) were utilized selectively. Mean operative time was 236 +/- 60 min and mean blood loss was 244 +/- 516 ml. There was one conversion to an open procedure because of bleeding from the splenic vein. The mean postoperative LOS was 4.5 +/- 2.0 days. Seven patients experienced a total of ten postoperative complications, including a urinary tract infection (UTI) (1), lower-extremity deep venous thrombosis (DVT) and pulmonary embolus (1), infected peripancreatic fluid collection (1), pancreatic pseudocyst (1), and pancreatic fistula (6). Five pancreatic fistulas were managed by percutaneous drainage. The reoperation rate was 4.5% and the overall pancreatic-related complication rate was 36.4%. One patient developed pancreatitis and a pseudocyst 5 months postoperatively, which was managed successfully with a pancreatic duct stent. There was no 30-day mortality.

CONCLUSIONS

Laparoscopic pancreatic resection is safe and feasible in selected patients with pancreatic neoplasms. With a pancreatic duct leak rate of 27%, this problem remains an area of development for the minimally invasive technique.

Pooled data analysis of laparoscopic vs. open ventral hernia repair: 14 years of patient data accrual

BACKGROUND

The purpose of this study was to analyze the published perioperative results and outcomes of laparoscopic (LVHR) and open (OVHR) ventral hernia repair focusing on complications and hernia recurrences.

METHODS

Data were compiled from all English-language reports of LVHR published from 1996 through January 2006. Series with fewer than 20 cases of LVHR, insufficient details of complications, or those part of a larger series were excluded. Data were derived from 31 reports of LVHR alone (unpaired studies) and 14 that directly compared LVHR to OVHR (paired studies). Chi-squared analysis, Fisher's exact test, and two-tailed t-test analysis were used.

RESULTS

Forty-five published series were included, representing 5340 patients (4582 LVHR, 758 OVHR). In the pooled analysis (combined paired and unpaired studies), LVHR was associated with significantly fewer wound complications (3.8% vs. 16.8%, p < 0.0001), total complications (22.7% vs. 41.7%, p < 0.0001), hernia recurrences (4.3% vs. 12.1%, p < 0.0001), and a shorter length of stay (2.4 vs. 4.3 days, p = 0.0004). These outcomes maintained statistical significance when only the paired studies were analyzed. In the pooled analysis, LVHR was associated with fewer gastrointestinal (2.6% vs. 5.9%, p < 0.0001), pulmonary (0.6% vs. 1.7%, p = 0.0013), and miscellaneous (0.7% vs. 1.9%, p = 0.0011) complications, but a higher incidence of prolonged procedure site pain (1.96% vs. 0.92%, p = 0.0469); none of these outcomes was significant in the paired study analysis. No differences in cardiac, neurologic, septic, genitourinary, or thromboembolic complications were found. The mortality rate was 0.13% with LVHR and 0.26% with OVHR (p = NS). Trends toward larger hernia defects and larger mesh sizes were observed for LVHR.

CONCLUSIONS

The published literature indicates fewer wound-related and overall complications and a lower rate of hernia recurrence for LVHR compared to OVHR. Further controlled trials are necessary to substantiate these findings and to assess the health care economic impact of this approach.

Textile analysis of heavy weight, mid-weight, and light weight polypropylene mesh in a porcine ventral hernia model

BACKGROUND

The purpose of this study was to assess the burst strength and stiffness of heavy weight (HW), mid-weight (MW), and light weight (LW) polypropylene mesh pre-implantation and 5 months post-implantation in a porcine ventral hernia model.

MATERIALS AND METHODS

HW (95 g/cm2), MW (45 g/cm2), and LW (28 g/cm2) polypropylene were tested as dry samples (n = 8/mesh) before implantation using a stamp strain machine. Three weeks after creating four hernia defects in each mini-pig (n = 18), the polypropylene meshes (8 x 10 cm; 24/mesh type) were implanted in the preperitoneal space, ensuring 2 cm overlap circumferentially. At 5 months, the mesh was harvested en bloc with the abdominal wall. Testing of burst strength and stiffness was repeated on the ex vivo specimens.

RESULTS

After implantation in the pig for 5 months, the mean burst strength and stiffness of HW and MW meshes remains the same. LW mesh with an absorbable monofilament in its weave has significant reductions in mean burst strength (P = 0.01) and mean stiffness (P < 0.0001). The burst strength for all meshes tested was much higher than measured for the abdominal wall fascia alone. The degree of shrinkage of the various weight meshes did not differ.

CONCLUSION

A reduction in mean burst strength and stiffness occurs after 5 months implantation of LW polypropylene mesh with an absorbable monofilament. All meshes exhibited burst strengths that were much greater than the burst strength of the abdominal wall fascia alone. After tissue incorporation, the LW polypropylene mesh maintains mean burst strength comparable to MW polypropylene mesh, while becoming less stiff than HW mesh. Long-term, this may contribute to more physiological abdominal wall compliance after LW polypropylene mesh implantation.

Outcomes of laparoscopic paraesophageal hernia repair in elderly and high-risk patients

BACKGROUND

This study examines the impact of age and comorbidities on complications and outcomes of laparoscopic (Lap) paraesophageal hernia (PEH) repair.

METHODS

Data were collected prospectively on all patients who underwent Lap PEH repair from January 1995 through June 2005. Pre- and postoperative variables including complications were analyzed. Patients were stratified by age (Group [Gr.] 1, <65 years; Gr. 2, 65 to 74 years; Gr. 3, >/=75 years) and American Society of Anesthesiology (ASA) class (1 and 2 vs 3 and 4). Statistical analysis was performed using 1-way ANOVA, chi-square, and Fisher exact test.

RESULTS

Overall, 171 patients underwent Lap PEH repair. Mean patient age was 65 +/- 15 years, mean ASA class 2.4 +/- 0.5, gender 72% female, and mean operating time 173 +/- 49 min. Patients in Gr. 3 had a significantly higher ASA class (Gr. 1, 2.3 +/- 0.6; Gr. 2, 2.5 +/- 0.5; Gr. 3, 2.6 +/- 0.5) and longer postoperative length of stay (LOS) compared with Gr. 1 (P < 0.05). Esophageal lengthening was required in 10.4% of patients in Gr. 3 versus 2.6% in Gr. 1 and 2.1% in Gr. 2 (P = 0.079). Total complication rates were 17.1% in Gr. 1, 22.4% in Gr. 2, and 27.7% in Gr. 3 (P = not significant [NS]). Most complications were minor; grade 2 or higher complications occurred in 10.5% of patients in Gr. 1, 8.3% in Gr. 2, and 8.5% in Gr. 3 (P = NS). There was 1 death (Gr. 2) on postoperative day 18 due to a myocardial infarction (mortality rate = 0.6%). Mean follow-up was 25.3 +/- 20.6 months. Postoperative symptoms of heartburn and regurgitation were similar between groups as was antisecretory medication use. Anatomic failure of the repair occurred in 23.7% of patients with adequate follow-up: 26.7% in Gr. 1, 15.4% in Gr. 2, and 27.8% in Gr. 3 (P = NS). Reoperation was performed in 1 of 32 (3.1%) failures.

CONCLUSIONS

Lap PEH repair is safe in elderly and properly selected high-risk patients, although complication rates are higher than in younger patients. Most patients have a good symptomatic outcome irrespective of their age, but the anatomic recurrence rates remain a concern for all age groups.

Comparison of mechanical and in vivo performance of new and reprocessed harmonic scalpels

OBJECTIVES

To compare the mechanical and clinical performance of new and reprocessed harmonic scalpels (HS).

METHODS

A total of 89 reprocessed and 90 new HS (laparoscopic coagulating shears with a curved blade and 5-mm-diameter shaft) were subjected to visual inspection, destructive testing, and nondestructive mechanical testing. Subsequently, new HS, randomly selected reprocessed HS, and selected reprocessed HS with known abnormalities were graded on clinical performance by 14 surgeons in a porcine model.

RESULTS

Visual inspection of the HS discriminated between the new and reprocessed instruments in 11 of the 12 visual criteria (P < or = 0.02). In vitro mechanical testing revealed greater clamp arm dislodge forces for the new HS (P < 0.01) and greater midshaft temperatures for reprocessed HS (P < 0.01). Overall, 65 (73%) of 89 reprocessed and 7 (7.8%) of 90 new HS had gross abnormalities noted on inspection and mechanical evaluation (P < 0.01). The surgeons' evaluation of the instruments during in vivo testing demonstrated that the new instruments manifested significantly greater hemostatic control compared with randomly selected reprocessed HS (P = 0.01) and were significantly better for tissue sticking (P = 0.01), tissue transection (P = 0.02), tissue dissection (P < 0.01), grasping (P < 0.01), and hemostatic control (P = 0.04) compared with reprocessed HS with obvious defects.

CONCLUSIONS

In vitro and in vivo data demonstrated significantly greater performance for new HS compared with reprocessed HS. Mechanical testing of reprocessed HS could not adequately distinguish which HS would result in decreased performance. These findings raise important issues of clinical safety in the contemporary quest for cost-effectiveness.

Laparoscopic ventral hernia repair: a single center experience

A retrospective chart review at the Carolinas Medical Center was performed on all patients who underwent laparoscopic ventral hernia repair (LVHR) from July 1998 through December 2003. LVHR was successfully completed in 270 of the 277 patients, or 98%, in whom it was attempted. Half of the patients (138/277) had at least one previous failed repair. The average defect measured 143.3 cm(2), and mesh was used in all repairs. The mean operating time was 168.3 min, mean blood loss was 50 cc, and average length of hospitalization was 3.0 days. Thirty-four complications occurred in 31 patients (11%). Only two mesh infections occurred (0.7%). At a mean follow-up period of 21 months, the rate of hernia recurrence was 4.7%. As experience grows and length of follow-up expands, LVHR may become the preferred approach for ventral hernia in difficult patients, especially obese patients and patients who have failed prior open repairs.

Gas embolism during laparoscopic cholecystectomy

Advancements in laparoscopic surgery have resulted in decreased length of hospitalization, reduced postoperative pain, and better cosmesis following general surgical procedures. Carbon dioxide gas embolism is a rare occurrence that can be fatal. We report the case of a patient with a venous gas embolism during laparoscopic cholecystectomy. A 63-year-old woman presented with intermittent right upper quadrant pain, and her abdominal ultrasound showed a possible gallbladder polyp. A laparoscopic cholecystectomy was planned. A Veress needle was placed in the right upper quadrant to initiate abdominal access. Shortly after carbon dioxide insufflation, the patient's hemodynamic status deteriorated, her oxygen saturation dropped, and her end-tidal CO2 decreased. Gas insufflation was immediately stopped, and the patient was resuscitated. She stabilized quickly, and the procedure was performed without further event. She did well postoperatively and was discharged home the next day. Carbon dioxide embolism during laparoscopy, albeit rare, can be a fatal complication of the procedure. Whenever sudden changes in hemodynamic stability occur, venous gas embolism should be considered. As laparoscopic techniques and applications are expanded, the general surgeon must be aware of this entity.

Laparoscopic Ventral Hernia Repair in Obese Patients

HYPOTHESIS

Ventral abdominal hernias represent a frequent and often formidable clinical problem, especially in obese patients. Because laparoscopic ventral hernia repair (LVHR) results in few complications and a low recurrence rate, the use of minimally invasive techniques in this subgroup of patients may minimize perioperative complications and failure rates.

DESIGN

Retrospective review of prospectively collected data.

SETTING

Tertiary care hospital.

PATIENTS

One hundred sixty-three obese patients (body mass index [calculated as weight in kilograms divided by the square of height in meters], > or =30) who underwent LVHR at our institution between July 1, 1998, and December 31, 2003.

INTERVENTION

Laparoscopic ventral hernia repair with an expanded polytetrafluoroethylene mesh.

MAIN OUTCOME MEASURES

Patient age, sex, body mass index, size of fascial defect and mesh, operating time, operative blood loss, length of hospitalization, complications, and hernia recurrences.

RESULTS

Ninety-eight women and 65 men, with a mean body mass index of 38, underwent LVHR. Twenty patients (12.3%) had 21 postoperative complications. There was no perioperative mortality. The mean length of hospital stay was 2.6 days. The recurrence rate was 5.5% at a mean follow-up of 25 months (range, 1-73 months).

CONCLUSIONS

A low rate of conversion to laparotomy, minimal perioperative morbidity, and the absence of perioperative mortality in this series indicate the safety of LVHR in obese patients with complex hernias. In addition, a success rate of more than 94.5% suggests improved efficacy of LVHR compared with the historical rates among control subjects undergoing open surgery. In experienced hands, LVHR may be the approach of choice for most patients with a body mass index of 30 or more.

Normal intraabdominal pressure in healthy adults

BACKGROUND

Intraabdominal pressure (IAP) has been considered responsible for adverse effects in trauma and other abdominal catastrophes as well as in formation and recurrence of hernias. To date, little information is available concerning IAP in normal persons. Our purpose in this study was to measure the normal range of IAP in healthy, nonobese adults and correlate these measurements with sex and body mass index (BMI).

METHODS

After Institutional Review Board approval, 20 healthy young adults (< or =30 years old) with no prior history of abdominal surgery were enrolled. Pressure readings were obtained through a transurethral bladder (Foley) catheter. Each subject performed 13 different tasks including standing, sitting, bending at the waist, bending at the knees, performing abdominal crunches, jumping, climbing stairs, bench-pressing 25 pounds, arm curling 10 pounds, and performing a Valsalva and coughing while sitting and also while standing. Data were analyzed by Student's t-test and Pearson's correlation coefficients.

RESULTS

Intraabdominal pressure was measured in 10 male and 10 female subjects. The mean age of the study group was 22.7 years (range, 18-30 years), and BMI averaged 24.6 kg/m(2) (range, 18.4-31.9 kg/m(2)). Mean IAP for sitting and standing were 16.7 and 20 mm Hg. Coughing and jumping generated the highest IAP (107.6 and 171 mm Hg, respectively). Lifting 10-pound weights and bending at the knees did not generate excessive levels of pressure with the maximum average of 25.5 mm Hg. The mean pressures were not different when comparing males and females during each maneuver. There was a significant correlation between higher BMI and increased IAP in 5 of 13 exercises.

CONCLUSION

Normal IAP correlates with BMI but does not vary based on sex. The highest intraabdominal pressures in healthy patients are generated during coughing and jumping. Based on our observations, patients with higher BMI and chronic cough appear to generate significant elevation in IAP. Thus, this group of patients may potentially be at increased risk for abdominal wall hernia formation following surgery.

Prospective, blinded evaluation of accuracy of operative reports dictated by surgical residents

Incomplete or inaccurate operative notes result in delayed, reduced, or denied reimbursement. Deficient reports may be more common when dictated by the surgical residents. We performed a blinded study to assess the accuracy of residents' dictations and their effect on the appropriate level of coding for reimbursement. A prospective, blinded study was performed comparing operative reports dictated by senior surgical residents (postgraduate years 3, 4, and 5) to reports dictated by attending surgeons. All residents had previously undergone group instruction on the importance and structure of operative notes. The trainees were blinded to the fact that the attending surgeons were dictating the operative reports on a separate dictation system. The dictations were analyzed by faculty reimbursement billing personnel for accuracy and completeness. Fifty operative reports of general surgical procedures dictated by both surgical residents and attending physicians were reviewed. A total of 97 CPT codes were used to report services rendered. Residents' dictations resulted in incorrect coding in 14 cases (28% error rate). The types of inaccuracies were a completely missed procedure (4) and insufficient documentation for an appropriate CPT code and/or modifier (10). All deficiencies occurred in complex, multicode, and/or laparoscopic cases. Sixty-seven per cent of late dictations were incomplete. The financial analysis revealed that deficiencies in resident dictations would have reduced the reimbursement by $18,200 (9.7%). For cases with deficient dictations, 29.5 per cent of charges would have been missed, delayed, or denied if the resident-dictated note was used to justify charges. Operative reports dictated by surgical residents are often incomplete or inaccurate, likely leading to reduced or delayed reimbursement. Dictations of complex, multicode, or laparoscopic surgeries, especially if delayed beyond 24 hours, are likely to contain significant deficiencies that affect billing. Attending surgeons may be better equipped to dictate complex cases. Formal housestaff education, mentorship by the attending faculty, and ongoing quality control may be paramount to minimize documentation errors to ensure appropriate coding for the services rendered.

Laparoscopic curative resection of pheochromocytomas

PURPOSE

Pheochromocytomas are relatively uncommon tumors whose operative resection has clear medical and technical challenges. While the safety and efficacy of laparoscopic adrenalectomy are relatively well documented, few studies with extended follow-up have been conducted to measure the success of the procedure for the most challenging of the adrenal tumors. In addition, several reports question the applicability of a minimally invasive approach for sizeable pheochromocytomas. The purpose of our investigation was to assess the outcomes of laparoscopic adrenalectomy for pheochromocytomas in the largest study to date when performed by experienced laparoscopic surgeons.

METHODS

All pheochromocytomas removed by the authors from January 1995 to October 2004 were reviewed under an Institutional Review Board approved protocol. Eighty-five percent were documented in a prospective fashion.

RESULTS

Eighty consecutive patients underwent laparoscopic resection of 81 pheochromocytomas. Seventy-nine were found in the adrenal (42 left, 35 right, 1 bilateral); 2 were extra-adrenal paragangliomas. Eight patients had multiple endocrine neoplasia syndrome. Two lesions were malignant. There were 48 females and 32 males with a mean age of 45 years (range, 15-79 years). Mean tumor size was 5.0 cm (range, 2-12.1 cm); 41 of these lesions were 5 cm in size or larger. Average operative time and blood loss were 169 minutes (range, 69-375 minutes) and 97 mL (range, 20-500 mL), respectively. Intraoperative hypertension (systolic blood pressure, >170 mm Hg) was reported in 53% of patients and hypotension (systolic blood pressure, <90 mm Hg) in 28% of patients. There were no conversions to open surgery. Mean length of stay was 2.3 days (range, 1-10 days). There were 6 perioperative morbidities (7.5%) and no mortalities. No patient required a blood transfusion. No recurrence of endocrinopathy has been documented at a mean follow-up of 21.4 months.

CONCLUSION

Laparoscopic resection of pheochromocytomas, including large lesions, can be accomplished safely by experienced surgeons. A short hospital stay with minimal operative morbidity and eradication of endocrinopathy support the minimally invasive approach for adrenalectomy in the setting of pheochromocytoma.

Do patient or hospital demographics predict cholecystectomy outcomes? A nationwide study of 93,578 patients

BACKGROUND

The purpose of this study was to examine the influence of patient and hospital demographics on cholecystectomy outcomes.

METHODS

Year 2000 data from the Healthcare Cost and Utilization Project Nationwide Inpatient Sample database was obtained for all patients undergoing inpatient cholecystectomy at 994 nationwide hospitals. Differences (p < 0.05) were determined using standard statistical methods.

RESULTS

Of 93,578 cholecystectomies performed, 73.4% were performed laparoscopically. Length of hospital stay (LOS), charges, morbidity, and mortality were significantly less for laparoscopic cholecystectomy (LC). Increasing patient age was associated with increased LOS, charges, morbidity, mortality, and a decreased LC rate. Charges, LOS, morbidity, and mortality were highest for males with a lower LC rate than for females Mortality and LOS were higher, whereas morbidity was lower for African Americans than for whites. Hispanics had the shortest LOS, as well as the lowest morbidity and mortality rates. Laparoscopic cholecystectomy was performed more commonly for Hispanics than for whites or African Americans, with lower charges for whites. Medicare-insured patients incurred longer LOS as well as higher charges, morbidity, and mortality than Medicaid, private, and self-pay patients, and were the least likely to undergo LC. As median income decreases, LOS increases, and morbidity decreases with no mortality effect. Teaching hospitals had a longer LOS, higher charges, and mortality, and a lower LC rate, with no difference in morbidity, than nonteaching centers. As hospital size (number of beds) increased, LOS, and charges increased, with no difference in morbidity. Large hospitals had the highest mortality rates and the lowest incidence of LC. Urban hospitals had higher LOS and charges with a lower LC rate than rural hospitals. After control was used for all other covariates, increased age was a predictor of increased morbidity. Female gender, LC, and intraoperative cholangiogram all predicted decreased morbidity. Increased age, complications, and emergency surgery predicted increased mortality, with laparoscopy and intraoperative cholangiogram having protective effects. Patient income, insurance status, and race did not play a role in morbidity or mortality. Academic or teaching status of the hospital also did not influence patient outcomes.

CONCLUSIONS

Patient and hospital demographics do affect the outcomes of patients undergoing inpatient cholecystectomy. Although male gender, African American race, Medicare-insured status, and large, urban hospitals are associated with less favorable cholecystectomy outcomes, only increased age predicts increased morbidity, whereas female gender, laparoscopy, and cholangiogram are protective. Increased age, complications, and emergency surgery predict mortality, with laparoscopy and intraoperative cholangiogram having protective effects.

Laparoscopic management of median arcuate ligament syndrome

Median arcuate ligament syndrome is a rare disorder resulting from luminal narrowing of the celiac artery by the insertion of the diaphragmatic muscle fibers or fibrous bands of the celiac nervous plexus. The syndrome is characterized by weight loss, postprandial abdominal pain, nausea, vomiting, and an epigastric bruit. Surgical management entails complete division of the median arcuate ligament. The video demonstrates the laparoscopic release of the median arcuate ligament in a patient with median arcuate ligament syndrome. The patient is a 22-year-old male with a 6-month history of epigastric abdominal pain, nausea, vomiting, a 140-lb. weight loss, and an epigastric bruit on physical exam. Aortography demonstrated a >or=90% extrinsic compression of the celiac artery. A full laparoscopic skeletonization of the celiac artery and branch vessels was performed. Intraoperative duplex U/S demonstrated flow rate reduction after the median arcuate ligament release. A postoperative CT angiogram demonstrated no residual stenosis. The patient was discharged on postoperative day 3 and remained asymptomatic after 7 months of follow-up. Laparoscopic release of the median arcuate ligament is a novel approach to the management of celiac artery compression syndrome. The role of minimally invasive techniques to manage median arcuate ligament syndrome is evolving but they appear to be a safe alternative to open surgery.

Laparoscopic splenectomy for splenic abscess

Splenic abscess is a rare clinical entity, and splenectomy remains the treatment of choice. We sought to determine the safety and efficacy of laparoscopic splenectomy in this setting. Using a prospective database of laparoscopic splenectomy, we identified 4 patients who underwent surgery for splenic abscess (3 male, 1 female). Mean age was 55.5 (range 42-78) years. Patient symptoms included: fever and abdominal pain in 4 patients, pleural effusions in 2, and nausea and leukocytosis in 1. Risk factors for splenic abscess included septic emboli from bacterial endocarditis in 2 patients and acquired immune deficiency syndrome in 1. All patients underwent successful laparoscopic splenectomy. Mean operative time was 200 (range 160-220) minutes, and blood loss was 220 (range 100-450) mL. There were no postoperative complications or deaths; postoperative length of stay averaged 14 (range 2-26) days. Despite the difficulty of the operation, the laparoscopic approach appears to be a safe and effective treatment of splenic abscess.

National Study of the Effect of Patient and Hospital Characteristics on Bariatric Surgery Outcomes

The influence of patient and hospital demographics on gastric bypass (GB) outcomes is unknown. We analyzed year 2000 data from the Nationwide Inpatient Sample database for all GB patients. In 2000, 5876 GB were performed in the 137 sample hospitals (M:F, 14%:86%). Length of stay (LOS, days), charges, comorbidities, and morbidity were higher for those aged >60 years compared to <40 years. LOS, charges, comorbidities, morbidity, and mortality were highest in males. LOS was longest in African Americans compared to Caucasians and Hispanics. Charges and comorbidities were greatest in African Americans and Hispanics compared to Caucasians. Medicare and Medicaid-insured patients have higher LOS, charges, comorbidities, morbidity, and mortality compared to privately insured and self-pay patients. Lower income patients have higher LOS and total charges. Nonteaching hospitals have an increased LOS and charges and treat patients with more comorbidities compared to teaching hospitals. LOS, charges, and morbidity are directly proportional to hospital size. Urban hospitals have lower LOS and higher charges compared to rural hospitals. As hospital GB volume increases, LOS, charges, and morbidity decrease with no mortality effect. After controlling for all other covariates, male gender, increased age, and large hospital size were predictors of increased morbidity. Having had a complication predicted increased mortality, while female gender had a protective effect. Patient income, insurance status, and race did not play a role in morbidity or mortality. Neither academic, teaching status of the hospital or hospital gastric bypass volume influenced patient outcomes. Patient and hospital demographics do affect the outcomes of patients undergoing GB. Increasing age, male gender, and surgery performed in large hospitals are predictors of morbidity. Male gender and postoperative complications predict increased mortality. Neither comorbidities, race, payer, income, hospital academic status, location, nor hospital volume affect the outcome after GB.

National study of the effect of patient and hospital characteristics on bariatric surgery outcomes

The influence of patient and hospital demographics on gastric bypass (GB) outcomes is unknown. We analyzed year 2000 data from the Nationwide Inpatient Sample database for all GB patients. In 2000, 5876 GB were performed in the 137 sample hospitals (M:F, 14%:86%). Length of stay (LOS, days), charges, comorbidities, and morbidity were higher for those aged >60 years compared to < 40 years. LOS, charges, comorbidities, morbidity, and mortality were highest in males. LOS was longest in African Americans compared to Caucasians and Hispanics. Charges and comorbidities were greatest in African Americans and Hispanics compared to Caucasians. Medicare and Medicaid-insured patients have higher LOS, charges, comorbidities, morbidity, and mortality compared to privately insured and self-pay patients. Lower income patients have higher LOS and total charges. Nonteaching hospitals have an increased LOS and charges and treat patients with more comorbidities compared to teaching hospitals. LOS, charges, and morbidity are directly proportional to hospital size. Urban hospitals have lower LOS and higher charges compared to rural hospitals. As hospital GB volume increases, LOS, charges, and morbidity decrease with no mortality effect. After controlling for all other covariates, male gender, increased age, and large hospital size were predictors of increased morbidity. Having had a complication predicted increased mortality, while female gender had a protective effect. Patient income, insurance status, and race did not play a role in morbidity or mortality. Neither academic, teaching status of the hospital or hospital gastric bypass volume influenced patient outcomes. Patient and hospital demographics do affect the outcomes of patients undergoing GB. Increasing age, male gender, and surgery performed in large hospitals are predictors of morbidity. Male gender and postoperative complications predict increased mortality. Neither comorbidities, race, payer, income, hospital academic status, location, nor hospital volume affect the outcome after GB.

Evaluation of adhesion formation, mesh fixation strength, and hydroxyproline content after intraabdominal placement of polytetrafluoroethylene mesh secured using titanium spiral tacks, nitinol anchors, and polypropylene suture or polyglactin 910 suture

BACKGROUND

The purpose of this study is to evaluate fixation methods for polytetrafluoroethylene (ePTFE) mesh with an in vivo model of laparoscopic ventral hernia repair.

METHODS

In 40 New Zealand white rabbits, a 4 x 4-cm ePTFE mesh (n = 80, two per animal) was attached to an intact peritoneum with polyglactin 910 (PG 910) (n = 20) or polypropylene (PP) (n = 20) suture, titanium spiral tacks (TS) (n = 20), or nitinol anchors (NA) (n = 20). Mesh was harvested at 8 and 16 weeks for fixation strength testing, adhesion assessment, and collagen (hydroxyproline) content. Fixation strength on day 0 was determined with mesh attached to harvested abdominal wall. Statistical significance was determined as p < 0.05.

RESULTS

There was no difference in fixation strength between PP (39.1 N) and PG 910 (40.0 N) sutures at time zero. At week 8, PP (25.7 N) was significantly stronger (p < 0.05) than PG 910 (11.4 N) suture, but not at week 16. The fixation strength of TS and NA (day 0, 15.4 vs 7.4 N; week 8, 17.5 vs 15.3 N; week 16, 19.1 vs 13.8 N) was not significantly different. Fixation with PP suture was significantly (p < 0.05) stronger than that with TS and NA at day 0 (39.1, 15.4, and 7.4 N, respectively) but not at weeks 8 or 16. The fixation strength of suture decreased significantly (p < 0.05) from day 0 to week 16 (PP: day 0 = 39.1 N, week 8 = 25.7 N, week 16 = 21.4 N; PG 910: day 0 = 40.0 N, week 8 = 11.4 N, week 16 = 12.8 N). The fixation strength of NA and TS did not change significantly (NA: day 0 = 7.4 N, week 8 = 15.3 N, week 16 = 13.8 N; TS: week 0 = 15.4 N, week 8 = 17.5 N, week 16 = 19.1 N). There were no differences in adhesion area based on fixation device used; however, there were more (p < 0.05) mesh samples using NA with adhesions compared to TS and adhesion tenacity was greater (p < 0.05) compared to that of TS, PP, and PG. Hydroxyproline content at weeks 8 and 16 was similar for all fixation devices.

CONCLUSIONS

The initial fixation strength for nonabsorbable suture is significantly greater than that of the metallic fixation devices, but after 8 weeks there is no difference. Laparoscopic ventral hernia repair without transabdominal suture fixation may be predisposed to acute failure. The metallic devices have similar fixation strength, although the incidence of adhesions and tenacity of adhesions appear to be greater with the nitinol anchors. Since these devices have similar fixation strengths and most likely provide adequate supplementation to transabdominal sutures for mesh fixation after laparoscopic ventral hernia repair, their use should be based on other factors, such as their propensity for adhesions, ease of application, and cost.

Evaluation of adhesion formation and host tissue response to intra-abdominal polytetrafluoroethylene mesh and composite prosthetic mesh

BACKGROUND

The purpose of this study was to measure the extent of adhesion formation to ePTFE mesh (DualMesh, W.L. Gore & Associates, Inc, Flagstaff, AZ) and two composite prosthetic materials, ePTFE and polypropylene (Bard Composix, C.R. Bard, Inc, Murray Hill, NJ) and hyaluronic acid/carboxymethylcellulose and polypropylene (Sepramesh, Genzyme Corp, Cambridge, MA) after their intra-abdominal placement on an intact peritoneum, simulating laparoscopic ventral hernia repair, and to evaluate host tissue response to the prosthetic biomaterials.

MATERIALS AND METHODS

Through a midline laparotomy, a 2 x 2 cm piece of mesh (n = 60) was sewn to an intact peritoneum on each side of a midline incision in 30 New Zealand white rabbits. Mesh adhesions were scored using a modified Diamond scale (0 = 0%, 1 = 1-25%, 2 = 26-50%, 3 >50%) at 1, 3, 9, and 16 weeks by serial microlaparoscopy (2 mm). All laparoscopic evaluations were videotaped for blinded scoring by three surgeons. Host tissue response was graded (1-4) for inflammation, tissue ingrowth, and mesothelialization. The predominant cell type (polymorphonuclear leukocytes versus foreign body giant cell) was recorded. Statistical differences (P value <0.05*) were measured using a two-tailed t test and Kruskal-Wallis test.

RESULTS

The mean adhesion score was significantly (P < 0.001) less for ePTFE mesh at 1, 3, 9, and 16 weeks compared with the two composite prosthetic materials. There were no differences in the mean adhesion scores between the two biosurgical composite meshes at any of the time intervals. There were no differences in the mean score for inflammation, tissue ingrowth and mesothelialization between any of the prosthetic biomaterials. The predominant cell type on all histological evaluations was polymorphonuclear leukocytes.

CONCLUSIONS

Placing ePTFE mesh (DualMesh) intra-abdominal against an intact peritoneum results in significantly fewer adhesions than the composite prosthetic meshes during a 4-month follow-up. The host tissue response is equivalent for the three prosthetic biomaterials. The long-term consequences of increased adhesion formation to the composite meshes and the ultimate biocompatibility of the nonabsorbable and absorbable barriers on the polypropylene mesh are to be determined.

Laparoscopic resection of splenic artery aneurysms

BACKGROUND

Laparoscopic techniques used to manage asymptomatic splenic artery aneurysms have been reported infrequently.

METHODS

A laparoscopic splenic artery aneurysm resection was attempted for six consecutive patients.

RESULTS

One patient underwent conversion to laparotomy because of a tear in the splenic vein. Among the five successful laparoscopic splenic artery aneurysm resections, the mean estimated blood loss was 37 +/- 12.6 ml, the mean operative time was 187.6 +/- 79.2 min, and the mean postoperative length of hospital stay was 1.8 +/- 1.3 days. The mean time to a clear liquid diet was 5.3 +/- 0.5 h, and the mean time to a regular diet was 1 +/- 0 day. The mean duration of narcotic analgesic use was 5.4 +/- 1.5 days, and the mean time to resumption of regular activities was 12.7 +/- 1.6 days.

CONCLUSIONS

These cases illustrate the benefit of a laparoscopic approach with brief hospitalizations, early resumption of diet and regular activity, and minimal use of postoperative narcotic analgesics.

Effect of carbon dioxide pneumoperitoneum and wound closure technique on port site tumor implantation in a rat model

BACKGROUND

The purpose of this study was to evaluate the effects of carbon dioxide (CO2) pneumoperitoneum and wound closure technique on port site tumor implantation.

METHODS

A standard quantity of rat mammary adenocarcinoma (SMT2A)was allowed to grow in a flank incision in Wistar-Furth rats (n = 90) for 14 days. Thereafter, 1-cm incisions were made in each animal in three quadrants. There were six control animals. The experimental animals were divided into a 60-min CO2 pneumoperitoneum group (n = 42) and a no pneumoperitoneum (n = 42) group. The flank tumor was lacerated transabdominally in the experimental groups. The three wound sites were randomized to closure of (a) skin; (b) skin and fascia; and (c) skin, fascia, and peritoneum. The abdominal wounds were harvested en bloc on postoperative day 7.

RESULTS

Histologic comparison of the port sites in the pneumoperitoneum and no-pneumoperitoneum groups did not demonstrate a statistically significant difference in tumor implantation for any of the closure methods. Evaluation of the closure techniques showed no statistical difference between the pneumoperitoneum group and the no-pneumoperitoneum group in the incidence of port site tumor implantation. Within the no-pneumoperitoneum group, there was a significant increase (p = 0.03) in tumor implantation with skin closure alone vs all three layers. Additionally, when we compared all groups by closure technique, the rate of tumor implantation was found to be significantly higher (p = 0.01) for skin closure alone vs closure of all three layers.

CONCLUSIONS

This study suggests that closure technique may influence the rate of port site tumor implantation. The use of a CO2 pneumoperitoneum did not alter the incidence of port site tumor implantation at 7 days postoperatively.

Cirrhosis is not a contraindication to laparoscopic surgery

BACKGROUND

Cirrhosis of the liver contributes significantly to morbidity and mortality in abdominal surgery. The proven benefits of laparoscopy seem especially applicable to patients with this complex disease. This study evaluates the safety and efficacy of laparoscopic procedures in a series of consecutively treated patients with biopsy-proven cirrhosis.

METHODS

The medical records of all patients with biopsy-proven cirrhosis undergoing laparoscopic surgery at the authors' medical center between January 2000 and December 2003 were retrospectively reviewed.

RESULTS

A total of 50 patients (27 men and 23 women) underwent 52 laparoscopic procedures. Among these 50 patients were 39 patients with Child-Pugh classification A cirrhosis, 10 with classification B, and 1 with classification C, who underwent a variety of laparoscopic procedures including cholecystectomy (n = 22), splenectomy (n = 18), colectomy (n = 4), diagnostic laparoscopy (n = 3), ventral hernia repair (n = 1), Nissen fundoplication (n = 1), Heller myotomy (n = 1), Roux-en-Y gastric bypass (n = 1), and radical nephrectomy (n = 1). There were two conversions (4%) to an open procedure. The mean operative time was 155 min. Estimated blood loss averaged 124 ml for all procedures, and 20 patients (40%) required perioperative transfusion of blood products. One patient required a single blood transfusion postoperatively because of anemia. No one experienced hepatic decompensation. Overall morbidity was 16%. There were no deaths. The mean length of hospitalization was 3 days.

CONCLUSIONS

Although technically challenging because portal hypertension, varices, and thrombocytopenia frequently coexist, basic and advanced laparoscopic procedures are safe for patients with mild to moderate cirrhosis of the liver.

The laparoscopic repair of suprapubic ventral hernias

BACKGROUND

The complexity of dissection and the close proximity of the hernia to bony, vascular, nerve, and urinary structures make the laparoscopic repair of suprapubic hernias (LRSPH) a formidable operation. We performed a prospective evaluation of the outcomes of patients undergoing LRSPH.

METHODS

The study population comprised 36 patients undergoing LRSPH from July 1996 to January 2004. Patient demographics, hernia sizes, mesh types and sizes, perioperative outcomes, and recurrences were documented. After our early experience with this operation, the repair evolved to include transabdominal suture fixation to the pubic bone, Cooper's ligament, and above the iliopubic tract.

RESULTS

There were 26 women and 10 men. They had a mean age of 55.9 years (range, 33-76) and a mean body mass index (BMI) of 31.0 kg/m2 (range, 22-67). Twenty-two (61%) of the repairs were for recurrent hernias, with an average of 2.3 previously failed open repairs each (range, 1-11). The mean hernia size was 191.4 cm2 (range, 20-768), and the average mesh size was 481.4 cm2 (range, 193-1,428). All repairs were performed with expanded polytetrafluoroethylene (ePTFE) mesh. Mean operating time was 178.7 min (range, 95-290). Mean blood loss was 40 cc (range, 20-100). One patient undergoing her fifth repair required conversion due to adhesions to a polypropylene mesh. Hospital stay averaged 2.4 days (range, 1-7). Mean follow-up was 21.1 months (range, 1-70). Complications (16.6%) included deep venous thrombosis (n = 1), prolonged pain for >6 weeks (n = 1), trocar site cellulitis (n = 1), ileus (n = 1), prolonged seroma (n = 1), and Clostridium difficile colitis (n = 1). Hernias recurred in two of our first nine patients, for an overall recurrence rate of 5.5%. Since we began using the technique of applying multiple sutures directly to the pubis and Cooper's ligament (in the subsequent 27 patients), no recurrences have been documented.

CONCLUSIONS

Although technically demanding and time-consuming, the LRSPH is safe and technically feasible. Moreover, it results in a low recurrence rate and is applicable to large or multiply recurrent hernias. Transabdominal suture fixation to the bony and ligamentous structures produces a more durable hernia repair.

The susceptibility of prosthetic biomaterials to infection

BACKGROUND

Despite the use of a sterile technique and the administration of prophylactic antibiotics during surgical procedures, mesh infection continues to complicate the use of biomaterials. The purpose of this study was to compare the susceptibility to infection of prosthetic biomaterials in a live-animal model.

METHODS

The following seven prosthetic mesh biomaterials were used in this study. Expanded polytetrafluoroethylene (ePTFE) with silver/chlorhexidine (DM+), ePTFE (DM), porcine intestinal submucosa (S), polypropylene (M), ePTFE/polypropylene (X), hyaluronate/carboxymethylcellulose/polypropylene (SM), and human acellular dermal matrix (A). Lewis rats (n = 108) underwent creation of a single ventral hernia; 105 of them were repaired with a different mesh (2-cm2 piece). Twelve pieces of each mesh were inoculated at the time of hernia repair with 10(8) Staphylococcus aureus (n = 84). Three pieces of each mesh were placed without bacterial inoculation (n = 21). In three animals, no mesh was placed; instead, the peritoneum of the hernia defect was inoculated (n = 3). After 5 days, the animals were killed and the mesh was explanted (peritoneum for the nonmesh control). The mesh was vortex-washed and incubated in tryptic soy broth. Bacterial counts were determined using serial dilutions and spot plates and quantified in colony-forming units (CFU) per square centimeter of mesh present in the vortex wash fluid (wash count) and the soy broth (broth count). Data are presented as the mean log(10), with analysis of variance (ANOVA) and Tukey's test used to determine significance (p < 0.05).

RESULTS

The DM+ material had no detectable live bacteria in the wash or broth counts in 10 of 12 tested samples (p = 0.05). Of the samples that showed bacterial growth, the peritoneum control group had a lower wash count than A (p = 0.05) and the lowest broth count of all the materials except for DM+ (p = 0.05). In addition, SM had a significantly lower wash count than A (p = 0.05), with no broth count difference. In regard to wash and broth counts, DM, M, X, SM, S, and A were no different (p = NS).

CONCLUSIONS

The DM+ material was the least susceptible to infection. Impregnation with silver/chlorhexidine killed the inoculated bacteria, preventing their proliferation on the mesh surface. Other than DM+, native peritoneal tissue appears to be the least susceptible to infection. Silver/chlorhexidine appears to be an effective bactericidal agent for use with mesh biomaterials.

A novel technique of lumbar hernia repair using bone anchor fixation

Lumbar hernias are difficult to repair due to their proximity to bone and inadequate surrounding tissue to buttress the repair. We analyzed the outcome of patients undergoing a novel retromuscular lumbar hernia repair technique. The repair was performed in ten patients using a polypropylene or polytetrafluoroethylene mesh placed in an extraperitoneal, retromuscular position with at least 5 cm overlap of the hernia defect. The mesh was fixed with circumferential, transfascial, permanent sutures and inferiorly fixed to the iliac crest by suture bone anchors. Five hernias were recurrent, and five were incarcerated; seven were incisional hernias, and three were posttraumatic. Back and abdominal pain was the most common presenting symptom. Mean hernia size was 227 cm(2) (60-504) with a mesh size of 620 cm(2) (224-936). Mean operative time was 181 min (120-269), with a mean blood loss of 128 ml (50-200). Mean length of stay was 5.2 days (2-10), and morphine equivalent requirement was 200 mg (47-460). There were no postoperative complications or deaths. After a mean follow-up of 40 months (3-99) there have been no recurrences. Our sublay repair of lumbar hernias with permanent suture fixation is safe and to date has resulted in no recurrences. Suture bone anchors ensure secure fixation of the mesh to the iliac crest and may eliminate a common area of recurrence.

Colonoscopic perforations: incidence, management, and outcomes

Fiberoptic colonoscopy provides superior diagnostic and therapeutic capabilities in the treatment of lower gastrointestinal disease processes. A well-recognized, but uncommon, complication during the procedure is perforation. The purpose of this study was to determine the incidence of colonoscopic perforation, define risk factors, assess the management of these complications, and evaluate outcomes. From January 1997 through December 2003, 43,609 colonoscopies were performed in our medical center. There were 14 (0.032%) perforations (1 in 3115 procedures); 7 from diagnostic and 7 from therapeutic procedures. General surgeons performed 1243 procedures (2.9%), and their rate of perforation was 0.080 per cent compared with 0.031 per cent for gastroenterologists during the same period. Half of the perforations occurred in the rectosigmoid, and the most common mechanism was mechanical (n = 6). Perforation was identified immediately during endoscopy in 50 per cent of the patients. Thirteen of 14 perforations were treated within 24 hours; 1 was delayed 48 hours. Initial surgical management was undertaken in 11/14 patients. Initial nonoperative treatment was attempted in three and was successful in only one patient. The mean length of stay following perforation was 11.2 days (range, 4-36 days). Three patients (21.4%) had 7 postoperative complications. Colonoscopic perforations are uncommon but can be recognized early and managed surgically with acceptable morbidity and postoperative length of stay.

Colonoscopic Perforations: Incidence, Management, and Outcomes

Fiberoptic colonoscopy provides superior diagnostic and therapeutic capabilities in the treatment of lower gastrointestinal disease processes. A well-recognized, but uncommon, complication during the procedure is perforation. The purpose of this study was to determine the incidence of colonoscopic perforation, define risk factors, assess the management of these complications, and evaluate outcomes. From January 1997 through December 2003, 43,609 colonoscopies were performed in our medical center. There were 14 (0.032%) perforations (1 in 3115 procedures); 7 from diagnostic and 7 from therapeutic procedures. General surgeons performed 1243 procedures (2.9%), and their rate of perforation was 0.080 per cent compared with 0.031 per cent for gastroenterologists during the same period. Half of the perforations occurred in the rectosigmoid, and the most common mechanism was mechanical (n = 6). Perforation was identified immediately during endoscopy in 50 per cent of the patients. Thirteen of 14 perforations were treated within 24 hours; 1 was delayed 48 hours. Initial surgical management was undertaken in 11/14 patients. Initial nonoperative treatment was attempted in three and was successful in only one patient. The mean length of stay following perforation was 11.2 days (range, 4–36 days). Three patients (21.4%) had 7 postoperative complications. Colonoscopic perforations are uncommon but can be recognized early and managed surgically with acceptable morbidity and postoperative length of stay.

Advanced age is not a prohibitive factor in laparoscopic nephrectomy for renal pathology

Since the first procedure by Clayman and colleagues in 1990, laparoscopic nephrectomy has been performed at multiple institutions worldwide and is an accepted approach for benign and malignant renal pathology. We retrospectively compared the outcomes of laparoscopic nephrectomy for renal pathology in patients older than and less than 65 years of age. Data were collected for all patients undergoing elective nephrectomy (simple, radical, and nephroureterectomy) for renal pathology between November 2000 and June 2003. A total of 94 laparoscopic nephrectomies (62 hand-assisted, 32 totally laparoscopic) for renal disease were performed. Indications for surgery included renal cell carcinoma (63), transitional cell carcinoma (7), hypertension (9), chronic pyelonephritis (6), nonfunctioning kidney (4), complex cyst (3), and polycystic kidney disease (2). There were 33 elderly patients (> or = 65 years) and 61 adult patients (< 65 years). The elderly group had a mean operative time (238 min vs 234.3 min; P = 0.89) and blood loss (88.5 mL vs 149.8 mL; P = 0.68) similar to the adult group. Likewise, the incidence of perioperative complications was no different between the two groups (intra-op: 3.0% vs 0%; P = 0.35/post-op: 21.2% vs 16.4%; P = 0.56). The length of hospitalization was longer in the elderly population (5.7 days versus 5.0 days; P = 0.01) compared to the younger adult group. Laparoscopic nephrectomy is well tolerated in the elderly population. For all surgical indications, the use of a minimally invasive approach confers operative times, blood loss, and morbidity that are comparable to those of younger patients. Yet, length of stay remains longer for elderly patients undergoing nephrectomy.